Expert consensus on moving towards a value-based healthcare system in the Netherlands: a Delphi study

Patient-reported outcome measures in value-based healthcare: A multiple methods study to assess patient-centredness

OBJECTIVES

Value-based healthcare (VBHC) involves the use of standardised outcome measures, including patient-reported outcome measures (PROMs). This study aimed to assess to what extent discussion of PROMs is associated with patient- and person-centredness.

METHODS

This study used a separate sample pre-/post-test design and multiple methods (observations, questionnaires, and interviews) in a VBHC care pathway for patients with a vestibular schwannoma, to assess to what extent the implementation of PROMs is associated with a difference in patient- and person-centredness.

RESULTS

A total of 139 patients with a vestibular schwannoma and their four treating physicians were included in the study. No significant differences were found in observed patient-centredness (Mpre=6.71 ± 2.42 vs. Mpost=6.93 ± 2.01; P = 0.60) or patient-reported patient-centredness (Mpre=1.73 vs. Mpost=1.68; P = 0.63) and person-centredness after PROM implementation (Mpre=11.81 vs. Mpost=13.42; P = 0.34). We observed more discussion of patient-reported outcomes. However, a majority of patients did not expect PRO discussion in consultations.

CONCLUSIONS

The implementation of standardised PROMs in a VBHC care pathway was associated with more discussion on patient-reported outcomes in clinical consultations. Overall, the implementation of PROMs was not observed or perceived as leading to more patient-centred consultations.

PRACTICE IMPLICATIONS

Physicians should assess whether the discussion of PROMs add value collaboratively with patients.

Towards the Improvement of Patient Experience Evaluation Items for Patient-Centered Care in Head and Neck Cancer: A Qualitative Comparative Study

Owing to long-term treatment, frequent consultations, and complications, the evaluation of patients with head and neck cancer (HNC) must be improved. This study explored an opportunity for improving patient experience (PE) evaluation of patients with HNC to achieve a patient-centered, integrative evaluation model based on patient needs. The study comprised four phases: (1) a systematic literature review of PE factors for patient quality of life (QoL) and establishment of PE factor categories as a framework, (2) a review of current cancer or HNC PE evaluation tools, (3) identification of potential PE evaluation items based on patient needs by conducting user research, and (4) suggestion of integrative HNC PE evaluation items through expert validation. As a result, the 39 potential items were initially identified from the literature review and user research. After conducting two survey rounds with experts, 25 items were suggested as HNC PE evaluation items. These underscore the importance of highlighting the patient's participation, the medical staff's comprehensive information delivery, empathy, and collaborative communication, the hospital's support of communication channels, the medical environment for patient emotional support, the education program, and systematic patient satisfaction data management. PE evaluation items that consider the diverse perspectives of stakeholders involved in HNC treatment and factors of comprehensive PE will contribute to improving HNC patient-centered care (PCC).

Building a patient-centred nationwide integrated cardiac care registry: intermediate results from the Netherlands

This paper presents an overview of the development of an integrated patient-centred cardiac care registry spanning the initial 5 years (September 2017 to December 2022). The Netherlands Heart Registration facilitates registration committees in which mandated cardiologists and cardiothoracic surgeons structurally evaluate quality of care using real-world data. With consistent attendance rates exceeding 60%, a valuable network is supported. Over time, the completeness level of the registry has increased. Presently, four out of six quality registries show over 95% completeness in variables that are part of the quality policies of cardiology and cardiothoracic surgery societies. Notably, 93% of the centres voluntarily report outcomes related to open heart surgery and (trans)catheter interventions publicly. Moreover, outcomes after implantable cardioverter-defibrillator and pacemaker procedures are transparently reported by 26 centres. Multiple innovation projects have been initiated by the committees, signalling a shift from publishing outcomes transparently to collaborative efforts in sharing healthcare processes and investigating improvement initiatives. The next steps will focus on the entire pathway of cardiac care for a specific medical condition instead of focusing solely on the outcomes of the procedures. This redirection of focus to a comprehensive assessment of the patient pathway in cardiac care ultimately aims to optimise outcomes for all patients.

The importance and feasibility of hospital interventions to prevent and manage patient aggression and violence against physicians in China: a Delphi study

BACKGROUND

Aggression and violence by patient (and their relatives/friends) is widely acknowledged as a serious occupational hazard, with physicians being particularly susceptible to witnessing and experiencing such incidents within hospitals. Research has shown that the negative consequences of such aggression and violence are not only felt at the individual level, but also at the team and organizational levels. Understanding how to prevent and manage this behavior towards physicians in hospitals is urgent and not fully researched. While there are many potentially effective interventions, it is unclear which ones would be valuable and feasible for Chinese hospitals. Because patient aggression and violence may occur more frequently in Chinese hospitals than in other countries, this suggests that cultural differences play a role and that tailored interventions may be needed.

METHOD

We conducted a Delphi study to reach a consensus on the importance and feasibility of hospital interventions to prevent and manage patient (and their relatives/friends) aggression and violence against physicians in Chinese hospitals. Seventeen experts in China were invited to complete online questionnaires over three rounds.

RESULTS

After three rounds, consensus was achieved concerning 44 interventions, five other interventions were rejected, and no consensus was reached on another two. These interventions were clustered into eight categories: environment design, access and entrance, staffing and working practices, leadership and culture, training and education, support, during/after-the-event actions, and hospital policy. Each category is considered important in preventing and managing patient (and their relatives/friends) aggression and violence towards physicians in Chinese hospitals. This study also investigated the feasibility of the suggested interventions and found that 36 of the 44 interventions were considered not only relevant, but also feasible for implementation in Chinese hospitals.

CONCLUSIONS

This study provides an overview of interventions that can be implemented in Chinese hospitals to prevent and manage patient (and their relatives/friends) aggression and violence before, during, and after a violent incident occurs.

How to Use Costs in Value-Based Healthcare: Learning from Real-life Examples

BACKGROUND

Healthcare organizations measure costs for business operations but do not routinely incorporate costs in decision-making on the value of care.

AIM

Provide guidance on how to use costs in value-based healthcare (VBHC) delivery at different levels of the healthcare system.

SETTING AND PARTICIPANTS

Integrated practice units (IPUs) for diabetes mellitus (DM) and for acute myocardial infarction (AMI) at the Leiden University Medical Center and a collaboration of seven breast cancer IPUs of the Santeon group, all in the Netherlands.

PROGRAM DESCRIPTION AND EVALUATION

VBHC aims to optimize care delivery to the patient by understanding how costs relate to outcomes. At the level of shared decision-making between patient and clinician, yearly check-up consultations for DM type I were analyzed for patient-relevant costs. In benchmarking among providers, quantities of cost drivers for breast cancer care were assessed in scorecards. In continuous learning, cost-effectiveness analysis was compared with radar chart analysis to assess the value of telemonitoring in outpatient follow-up.

DISCUSSION

Costs vary among providers in healthcare, but also between provider and patient. The joint analysis of outcomes and costs using appropriate methods helps identify and optimize the aspects of care that drive desired outcomes and value.

Applications of the experience sampling method (ESM) in paediatric healthcare: a systematic review

BACKGROUND

With the Experience Sampling Method (ESM) participants are asked to provide self-reports of their symptoms, feelings, thoughts and behaviours in daily life. This preregistered systematic review assessed how ESM is being used to monitor emotional well-being, somatic health, fatigue and pain in children and adolescents with a chronic somatic illness.

METHODS

Databases were searched from inception. Studies were selected if they included children or adolescents aged 0-25 years with a chronic somatic illness and used ESM focussing on mental health or psychosocial wellbeing, biopsychosocial factors and/or somatic health. Two reviewers extracted data of the final 47 papers, describing 48 studies.

RESULTS

Most studies evaluated what factors influence medical or psychological symptoms and how symptoms influence each other. Another common purpose was to study the feasibility of ESM or ESM as part of an app or intervention. Study methods were heterogeneous and most studies lack adequate reporting of ESM applications and results.

CONCLUSIONS

While ESM holds great potential for providing results and feedback to patients and caregivers, little use is being made of this option. Future studies should consider what they report in their studies, conduct a priori power analyses and how ESM can be embedded in clinical practice.

IMPACT

While ESM has many clinical applications, it is currently mostly used for research purposes. Current studies using ESM are heterogeneous and lack consistent, high-quality reporting. There is great potential in ESM for providing patients and parents with personalised feedback.

Value-based healthcare implementation in the Netherlands: a quantitative analysis of multidisciplinary team performance

BACKGROUND

Many hospitals worldwide have set up multidisciplinary Value Improvement (VI) teams that use the Value-Based Health Care (VBHC) theory to improve patient value. However, it remains unclear what the level of VBHC implementation is within these teams. We therefore studied the current level of VBHC implementation in VI teams.

METHODS

A questionnaire was developed based on the strategic agenda for value transformation and real-world experiences with VBHC implementation. The questionnaire consisted of 21 questions, mapped to seven domains, and was sent out to 25 multidisciplinary VI teams. Median scores for individual questions (scale = 1-5) and average scores per domain were calculated.

RESULTS

One hundred forty VI team members completed the questionnaire. The overall average score is 3.49. The 'culture and responsibility' domain obtained the highest average score (µ = 4.11). The domain 'measure and improve outcomes' and the domain 'multidisciplinary team' obtained average scores that are slightly higher than the overall average (µ = 3.78 and µ = 3.76 respectively), and the domains 'strategy and organizational policy,' 'collaboration and sharing,' and 'IT and data' scored a little below the overall average (µ = 3.41, µ = 3.32, and µ = 3.29 respectively). The domain 'costs and reimbursement' obtained the lowest average score (µ = 2.42) of all domains, indicating that the implementation of this particular aspect of VBHC remains lagging behind.

CONCLUSIONS

Our results indicate activity in each of the questionnaire domains. To bring VBHC implementation to the next level, more attention should be given to the financial aspects. Our questionnaire can be used in future studies to identify improvements or differences within VI teams.

Value-Based Healthcare Delivery: A Scoping Review

Healthcare systems are transforming from the traditional volume-based model of healthcare to a value-based model of healthcare. Value generation in healthcare is about emphasising the health outcomes achieved by patients and organisations while maintaining an optimal relationship with costs. This scoping review aimed to identify the key elements and outcomes of implementing value-based healthcare (VBHC). The review process included studies published from 2013 to 2023 in four different databases (SpringerLink, PubMed, ProQuest and Scopus). Of the 2801 articles retrieved from the searches, 12 met the study's inclusion criteria. A total of 11 studies referred to value as the relationship between the outcomes achieved by patients and the costs of achieving those outcomes. Most of the studies highlighted the presence of leadership, the organisation of care into integrated care units, the identification and standardisation of outcome measures that generate value for the patient, and the inclusion of the patient perspective as the most prominent key elements for optimal VBHC implementation. Furthermore, some benefits were identified from VBHC implementation, which could shed light for future implementation actions. Therefore, the VBHC model is a promising approach that may contribute to an improvement in the efficiency and sustainability of healthcare.

The use of outcome data in patient consultations from the healthcare professionals' and patients' perspectives: A mixed methods study

OBJECTIVES

To gain insight into healthcare professionals' (HCPs') perspectives on the use of outcome data in consultations and to understand which aggregated outcomes patients find important.

METHODS

This study had a mixed-methods design and consisted of two steps: RESULTS: HCPs indicated that aggregated outcome data are not routinely used in consultations. They pointed out various barriers to using outcome data, e.g., low response rates of PROMs, and suggested actions to address these barriers, including training of HCPs in outcome data usage. Patients rated the majority of aggregated outcomes as important, although preferences differed between the studied health conditions.

CONCLUSION

Both HCPs and patients underscored the importance of discussing outcome data in consultations. Nevertheless, HCPs encountered several barriers to using outcome data. Furthermore, patients with different health conditions have somewhat different information needs.

PRACTICE IMPLICATIONS

The study identified several actionable steps to enhance the collection and application of outcome data in consultations.

Does value-based healthcare support patient-centred care? A scoping review of the evidence

BACKGROUND

Standardisation of outcome measures is integral to value-based healthcare (VBHC), which may conflict with patient-centred care, focusing on personalisation.

OBJECTIVES

We aimed to provide an overview of measures used to assess the effect of VBHC implementation and to examine to what extent the evidence indicates that VBHC supports patient-centred care.

DESIGN

A scoping review guided by the Joanna Briggs Institute methodology.

SOURCES OF EVIDENCE

We searched the following databases on 18 February 2021: Cochrane Library, EMBASE, MEDLINE and Web of Science.

ELIGIBILITY CRITERIA

We included empirical papers assessing the effect of the implementation of VBHC, published after introduction of VBHC in 2006.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers double-screened papers and data were extracted by one reviewer and checked by the other. We classified the study measures used in included papers into six categories: process indicator, cost measure, clinical outcome, patient-reported outcome, patient-reported experience or clinician-reported experience. We then assessed the patient-centredness of the study measures used.

RESULTS

We included 39 studies using 94 unique study measures. The most frequently used study measures (n=72) were process indicators, cost measures and clinical outcomes, which rarely were patient-centred. The less frequently used (n=20) patient-reported outcome and experience measures often measured a dimension of patient-centred care.

CONCLUSION

Our study shows that the evidence on VBHC supporting patient-centred care is limited, exposing a knowledge gap in VBHC research. The most frequently used study measures in VBHC research are not patient-centred. The major focus seems to be on measures of quality of care defined from a provider, institution or payer perspective.

The immaturity of patient engagement in value-based healthcare-A systematic review

Introduction

In recent years, Value-Based Healthcare (VBHC) has been gaining traction, particularly in hospitals. A core VBHC element is patient value, i.e., what matters most to the patient and at what cost can this be delivered. This interpretation of value implies patient engagement in patient-doctor communication. Although patient engagement in direct care in the VBHC setting is well described, patient engagement at the organizational level of improving care has hardly been studied. This systematic review maps current knowledge regarding the intensity and impact of patient engagement in VBHC initiatives. We focus on the organizational level of a continuous patient engagement model.

Methods

We performed a systematic review following PRISMA guidelines using five electronic databases. The search strategy yielded 1,546 records, of which 21 studies were eligible for inclusion. Search terms were VBHC and patient engagement, or similar keywords, and we included only empirical studies in hospitals or transmural settings at the organizational level.

Results

We found that consultation, using either questionnaires or interviews by researchers, is the most common method to involve patients in VBHC. Higher levels of patient engagement, such as advisory roles, co-design, or collaborative teams are rare. We found no examples of the highest level of patient engagement such as patients co-leading care improvement committees.

Conclusion

This study included 21 articles, the majority of which were observational, resulting in a limited quality of evidence. Our review shows that patient engagement at the organizational level in VBHC initiatives still relies on low engagement tools such as questionnaires and interviews. Higher-level engagement tools such as advisory roles and collaborative teams are rarely used. Higher-level engagement offers opportunities to improve healthcare and care pathways through co-design with the people being served. We urge VBHC initiatives to embrace all levels of patient engagement to ensure that patient values find their way to the heart of these initiatives.

Transforming Health Care Delivery towards Value-Based Health Care in Germany: A Delphi Survey among Stakeholders

Value-based healthcare (VBC) represents one strategy to meet growing challenges in healthcare systems. To date, VBC is not implemented broadly in the German healthcare system. A Delphi survey was conducted to explore stakeholders' perspectives on the relevance and feasibility of actions and practices related to the implementation of VBC in the German healthcare system. Panellists were selected using purposive sampling. Two iterative online survey rounds were conducted which were preceded by a literature search and semi-structured interviews. After two survey rounds, a consensus was reached on 95% of the items in terms of relevance and on 89% of the items regarding feasibility. The expert panels' responses were in favor of the presented actions and practices of VBC in 98% of items for which consensus was found (n = 101). Opposition was present regarding the relevance of health care being provided preferably in one location for each indication. Additionally, the panel considered inter-sectoral joint budgets contingent on treatment outcomes achieved as not feasible. When planning the next steps in moving towards a value-based healthcare system, policymakers should take into account this study's results on stakeholders' perceptions of the relative importance and feasibility of VBC components. This ensures that regulatory changes are aligned with stakeholder values, facilitating greater acceptance and more successful implementation.

Identifying consensus on activities that underpin value-based healthcare in outpatient specialty consultations, among clinicians

OBJECTIVE

To find a consensus on clinicians' and patients' activities that underpin an ideal value-based outpatient specialty consultation, among clinicians.

METHODS

A three-round online Delphi study was conducted. A purposive sample of nineteen clinicians from a Dutch university hospital judged activities on importance. Consensus was defined at 80% agreement. Activities were thematically analyzed to derive conceptual themes.

RESULTS

The expert panel agreed on 63 activities as being important for an ideal value-based outpatient specialty consultation and two activities as being unimportant. They failed to reach a consensus on 11 activities. Conceptual themes for activities that were considered important regard: 1) empowerment, 2) patient-reported biopsychosocial outcomes, 3) the patient as a person, 4) the patient's kin, 5) shared power and responsibility, 6) optimization, 7) coordination, 8) therapeutic relationships, and 9) resource-consciousness.

CONCLUSION

A value-based outpatient specialty consultation requires contextual decision-making, is person-centered, and focusses attention on care optimization and intelligent resource allocation. No importance is attributed to healthcare's societal burden and climate footprint. Disparities existed in various areas including the role of patient reported experience measures, "patient-like-me" data, and healthcare costs.

PRACTICE IMPLICATIONS

This study contributes a toolbox to guide and evaluate clinicians' and patients' behaviors in value-based outpatient specialty consultations and reveals opportunities to enhance facilitation.

Cost measurement in value-based healthcare: a systematic review

OBJECTIVE

Although value-based healthcare (VBHC) views accurate cost information to be crucial in the pursuit of value, little is known about how the costs of care should be measured. The aim of this review is to identify how costs are currently measured in VBHC, and which cost measurement methods can facilitate VBHC or value-based decision making.

DESIGN

Two reviewers systematically search the PubMed/MEDLINE, Embase, EBSCOhost and Web of Science databases for publications up to 1 January 2022 and follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify relevant studies for further analysis.

ELIGIBILITY CRITERIA

Studies should measure the costs of an intervention, treatment or care path and label the study as 'value based'. An inductive qualitative approach was used to identify studies that adopted management accounting techniques to identify if or how cost information facilitated VBHC by aiding decision-making.

RESULTS

We identified 1930 studies, of which 215 measured costs in a VBHC setting. Half of these studies measured hospital costs (110, 51.2%) and the rest relied on reimbursement amounts. Sophisticated costing methods that allocate both direct and indirect costs to care paths were seen as able to provide valuable managerial information by facilitating care path adjustments (39), benchmarking (38), the identification of cost drivers (47) and the measurement of total costs or cost savings (26). We found three best practices that were key to success in cost measurement: process mapping (33), expert input (17) and observations (24).

CONCLUSIONS

Cost information can facilitate VBHC. Time-driven activity-based costing (TDABC) is viewed as the best method although its ability to inform decision-making depends on how it is implemented. While costing short, or partial, care paths and surgical episodes produces accurate cost information, it provides only limited decision-making information. Practitioners are advised to focus on costing full care cycles and to consider both direct and indirect costs through TDABC.

Value-Based Healthcare From the Perspective of the Healthcare Professional: A Systematic Literature Review

Introduction: Healthcare systems increasingly move toward “value-based healthcare” (VBHC), aiming to further improve quality and performance of care as well as the sustainable use of resources. Evidence about healthcare professionals' contributions to VBHC, experienced job demands and resources as well as employee well-being in VBHC is scattered. This systematic review synthesizes this evidence by exploring how VBHC relates to the healthcare professional, and vice versa.

Method: Seven databases were systematically searched for relevant studies. The search yielded 3,782 records, of which 45 were eligible for inclusion based on a two-step screening process using exclusion criteria performed by two authors independently. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool (MMAT). Based on inductive thematic analysis, the Job Demands-Resources (JD-R) model was modified. Subsequently, this modified model was applied deductively for a second round of thematic analysis.

Results: Ten behaviors of healthcare professionals to enhance value in care were identified. These behaviors and associated changes in professionals' work content and work environment impacted the experienced job demands and resources and, in turn, employee well-being and job strain. This review revealed 16 constructs as job demand and/or job resource. Examples of these include role strain, workload and meaning in work. Four constructs related to employee well-being, including engagement and job satisfaction, and five constructs related to job strain, including exhaustion and concerns, were identified. A distinction was made between job demands and resources that were a pure characteristic of VBHC, and job demands and resources that resulted from environmental factors such as how care organizations shaped VBHC.

Conclusion and Discussion: This review shows that professionals experience substantial job demands and resources resulting from the move toward VBHC and their active role therein. Several job demands are triggered by an unsupportive organizational environment. Hence, increased organizational support may contribute to mitigating or avoiding adverse psychosocial factors and enhance positive psychosocial factors in a VBHC context. Further research to estimate the effects of VBHC on healthcare professionals is warranted.